Lost in Medication

Psychiatrists who take time with their patients are not the norm. It's not because others don't care. Rather the system rewards efficiency, not empathy.
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As a resident, I treated a patient who had suffered from schizophrenia for years. He had finally achieved some stability on a cocktail of antipsychotic medications as he was passed along through the clinic, year after year, from trainee doctor to trainee doctor. Despite doing relatively well, he continued to have auditory hallucinations, lack of interest, and low motivation. Antidepressants had been thrown into the mix, as well as a mood stabilizer or two, but he continued to suffer these symptoms.

One day, though, he showed up for his appointment looking completely different. His complaints had nearly disappeared; he was cheerful, optimistic. I felt like I was sitting in the room with a different person. Inquiring about what had changed, I found out that with the assistance of the hospital work program, he had gotten a job for the first time in nearly 30 years. He was working as a busboy in a restaurant, and felt a sense of purpose and meaning in his life again. "Doc, I finally have somewhere to go, where people need me."

In no other specialty does a physician define themselves by the medication that they use.

In many places psychiatry has become a biological enterprise, with some psychiatrists even introducing themselves as "psychopharmacologists." In no other specialty does a physician define themselves by the medication that they use. As one of my psychiatry professors once commented, "I have never met an oncologist who says "I'm an onco-pharmacologist." Increasingly, we are convinced that medications are what make patients better -- and that if only they would stay on them, if only they would take them as we have prescribed them, if only they were on the right one or the right dose -- they would get better.

In reality the process of getting better is much more complicated. Medications can play a large role, but other factors are enormously important -- environment, sense of purpose and meaning, the person's perception of their illness, and their relationship with the people who treat them. Studies have shown that patients taking placebo who have a good relationship with their psychiatrist have better outcomes than patients taking the active drug who do not have that strong personal connection. In the outpatient setting, a well-trained psychiatrist will follow what's called the biopsychosocial treatment model -- which values the biological, psychological, and social aspects of a person in considering their treatment -- and consider these other parts of the patient's healing process, in addition to medication.

For the person whose first encounter with psychiatry involves the inpatient psychiatric hospital ward, however, these psychosocial interventions are frequently left behind. Often under pressure from insurance companies, inpatient psychiatric units experience a tremendous push to medicate patients quickly and discharge them as soon as possible. During my time working on psychiatric units I saw instances where insurers balked at paying for the visit if the patient was not placed on any sort of medication.

Where once a psychiatric hospitalization meant a long stay working closely with a familiar staff and doing daily therapy -- with medication as an aide -- most modern experiences of psychiatric inpatients are far from this. Often involving numerous rotating caregivers working in shifts, moonlighters, or trainees on one rotation and off to another, patients often complain, "I only saw my doctor for ten minutes!" The more well-funded units have some form of therapy, usually group therapy with a behavioral focus, but many have very little of this to offer.

The experiences that lead to psychiatric hospitalization often raise philosophical questions, identity questions, emotions, and fears that the inpatient unit is sadly unequipped to deal with.

Overpopulated psych units resulting from hospitals trying to keep out of the red often lead to burned out staff members who would rather silence a psychotic, agitated, or complaining patient with medication than sit down and talk to them. I have seen nurses and doctors who do not give in to these pressures, who take the time with their patients, but they are sadly not the norm, not because others do not care, but rather because the system rewards efficiency, not empathy.

Presented by

Sarah Mourra, MD, is a fellow in geriatric psychiatry at UCLA. 

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